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Achilles Tendon Allograft Reconstruction of the Fibular Collateral Ligament and Posterolateral Corner Steve J. Schechinger, M.D., Bruce A. Levy, M.D., Khaled A. Dajani, M.D., Jay P. Shah, B.S., Diego A. Herrera, M.D., and Robert G. Marx, M.D., M.Sc., F.R.C.S.C. Purpose: The purpose of this study was to investigate the functional and clinical outcomes of a consecutive series of patients who underwent fibular collateral ligament (FCL) and posterolateral corner (PLC) reconstruction by use of a single Achilles tendon allograft construct. Methods: Patients were identified through prospective sports medicine databases at 2 academic institutions. Only patients who had undergone FCL and PLC reconstruction (as opposed to repair) were included. All patients followed a standard postoperative rehabilitation protocol. Various patterns of combined ligament injuries were included and divided into 2 groups (2 ligament v multiligament). Functional and clinical outcomes were assessed by clinical examination, Lysholm scores, and International Knee Documentation Committee subjective scores. Statistical analysis was performed by use of Wilcoxon paired rank-sum tests and multivariate regression. Results: We identified 16 knees in 16 patients, with a minimum of 2 years’ follow-up. There were 13 men and 3 women. The mean age was 30 years (range, 19 to 61 years). The mean length of clinical follow-up was 30 months (range, 24 to 75 months). The mean International Knee Documentation Committee subjective scores were 80 points and 80 points (P .79) in the 2-ligament and multiligament groups, respectively, and the mean Lysholm scores were 90 points and 89 points (P .96), respectively. Age (P .41), gender (P .84), and interval between injury and surgery (P .72) did not affect the clinical and functional outcomes between the 2 groups. Arthrofibrosis requiring manipulation developed in 1 patient. Residual varus laxity (1) was noted in 4 patients, none of whom displayed functional instability. No patient has required revision reconstruction to date. Conclusions: We describe a novel technique that takes into account the main static PLC stabilizers (FCL, popliteofibular ligament, and posterolateral capsule) that has not been previously reported. Our series showed no significant differences in clinical and functional outcomes between 2-ligament and multiligament PLC-based recon- structions. However, given the heterogeneity and small sample size of our study group, it is difficult to draw qualitative conclusions. Level of Evidence: Level IV, therapeutic case series. Key Words: Posterolateral corner—Knee ligament reconstruction—Fibular collateral ligament. I njuries to the posterolateral corner (PLC) are un- common 1 but potentially devastating. The most common mechanism of injury for this area of the knee involves a combined hyperextension and varus force to the extremity that is often high energy. 2 Because of this, the injury is often associated with other ligamen- tous deficiencies, which make the diagnosis and sur- gical reconstruction of this region extremely challeng- ing. 3 The anatomy of the PLC is complex and, until recently, has been relatively poorly understood. This region of the knee is composed of static and dynamic stabilizers. The 3 primary static stabilizers are the fibular collateral ligament (FCL), the popliteofibular ligament (PFL), and the posterolateral capsule. The popliteus tendon regulates both dynamic and static posterolateral rotation of the knee. 4-6 The PFL, which branches from the popliteus tendon and assumes its From the University of Minnesota (S.J.S., D.A.H.), Minneapolis, Minnesota; Mayo Clinic (B.A.L., K.A.D., J.P.S.), Rochester, Min- nesota; and Hospital for Special Surgery (R.G.M.), New York, New York, U.S.A. The authors report no conflict of interest. Received May 8, 2008; accepted September 15, 2008. Address correspondence and reprint requests to Bruce A. Levy, M.D., Department of Orthopaedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, U.S.A. E-mail: Levy.Bruce@ mayo.edu © 2009 by the Arthroscopy Association of North America 0749-8063/09/2503-8256$36.00/0 doi:10.1016/j.arthro.2008.09.017 232 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 3 (March), 2009: pp 232-242
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Page 1: Achilles Tendon Allograft Reconstruction of the Fibular Collateral ...

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Achilles Tendon Allograft Reconstruction of the FibularCollateral Ligament and Posterolateral Corner

Steve J. Schechinger, M.D., Bruce A. Levy, M.D., Khaled A. Dajani, M.D., Jay P. Shah, B.S.,Diego A. Herrera, M.D., and Robert G. Marx, M.D., M.Sc., F.R.C.S.C.

Purpose: The purpose of this study was to investigate the functional and clinical outcomes of aconsecutive series of patients who underwent fibular collateral ligament (FCL) and posterolateral corner(PLC) reconstruction by use of a single Achilles tendon allograft construct. Methods: Patients wereidentified through prospective sports medicine databases at 2 academic institutions. Only patients who hadundergone FCL and PLC reconstruction (as opposed to repair) were included. All patients followed astandard postoperative rehabilitation protocol. Various patterns of combined ligament injuries wereincluded and divided into 2 groups (2 ligament v multiligament). Functional and clinical outcomes wereassessed by clinical examination, Lysholm scores, and International Knee Documentation Committeesubjective scores. Statistical analysis was performed by use of Wilcoxon paired rank-sum tests andmultivariate regression. Results: We identified 16 knees in 16 patients, with a minimum of 2 years’follow-up. There were 13 men and 3 women. The mean age was 30 years (range, 19 to 61 years). Themean length of clinical follow-up was 30 months (range, 24 to 75 months). The mean International KneeDocumentation Committee subjective scores were 80 points and 80 points (P � .79) in the 2-ligament andmultiligament groups, respectively, and the mean Lysholm scores were 90 points and 89 points (P � .96),respectively. Age (P � .41), gender (P � .84), and interval between injury and surgery (P � .72) did notaffect the clinical and functional outcomes between the 2 groups. Arthrofibrosis requiring manipulationdeveloped in 1 patient. Residual varus laxity (1�) was noted in 4 patients, none of whom displayedfunctional instability. No patient has required revision reconstruction to date. Conclusions: We describea novel technique that takes into account the main static PLC stabilizers (FCL, popliteofibular ligament,and posterolateral capsule) that has not been previously reported. Our series showed no significantdifferences in clinical and functional outcomes between 2-ligament and multiligament PLC-based recon-structions. However, given the heterogeneity and small sample size of our study group, it is difficult todraw qualitative conclusions. Level of Evidence: Level IV, therapeutic case series. Key Words:Posterolateral corner—Knee ligament reconstruction—Fibular collateral ligament.

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njuries to the posterolateral corner (PLC) are un-common1 but potentially devastating. The most

ommon mechanism of injury for this area of the knee

From the University of Minnesota (S.J.S., D.A.H.), Minneapolis,innesota; Mayo Clinic (B.A.L., K.A.D., J.P.S.), Rochester, Min-

esota; and Hospital for Special Surgery (R.G.M.), New York, Nework, U.S.A.The authors report no conflict of interest.Received May 8, 2008; accepted September 15, 2008.Address correspondence and reprint requests to Bruce A. Levy,.D., Department of Orthopaedic Surgery, Mayo Clinic, 200irst St SW, Rochester, MN 55905, U.S.A. E-mail: [email protected]© 2009 by the Arthroscopy Association of North America

b0749-8063/09/2503-8256$36.00/0doi:10.1016/j.arthro.2008.09.017

32 Arthroscopy: The Journal of Arthroscopic and Related S

nvolves a combined hyperextension and varus forceo the extremity that is often high energy.2 Because ofhis, the injury is often associated with other ligamen-ous deficiencies, which make the diagnosis and sur-ical reconstruction of this region extremely challeng-ng.3

The anatomy of the PLC is complex and, untilecently, has been relatively poorly understood. Thisegion of the knee is composed of static and dynamictabilizers. The 3 primary static stabilizers are thebular collateral ligament (FCL), the popliteofibular

igament (PFL), and the posterolateral capsule. Theopliteus tendon regulates both dynamic and staticosterolateral rotation of the knee.4-6 The PFL, which

ranches from the popliteus tendon and assumes its

urgery, Vol 25, No 3 (March), 2009: pp 232-242

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233ACHILLES TENDON ALLOGRAFT RECONSTRUCTION

ourse to the fibular styloid, is an important stabilizerf external rotation.4-6 The FCL serves as the primarytatic restraint to varus opening of the knee. Theosterolateral capsule also provides static stability tohe knee with varus stress and supports the othertructures of the PLC. It is the combined effect ofhese complex anatomic structures that provides thearus and external rotatory constraints necessary for atable knee.

Anatomic reconstructions attempt to re-create theisrupted FCL, PFL, and popliteal tendon in each ofheir respective anatomic relations, insertions, and or-gins. These techniques vary between surgeons butssentially use a tunnel through the fibular head asell as a transtibial tunnel to facilitate graft passage

nd reconstruction of all 3 stabilizers.7 The anatomiceconstruction, popularized by other authors, hastrong biomechanical support but currently lacks clin-cal data.3,7-9

We developed a reconstructive technique that is lessomplex than some other anatomic techniques andoes not require the creation of a tibial tunnel anddditional graft passage. Our technique uses 1 Achil-es tendon allograft to reconstruct the FCL, the pop-iteus tendon, and the PFL, followed by a posterolat-ral capsular shift. To our knowledge, an outcometudy of this technique has not been previously re-orted.The purpose of this report is to present the clinical

nd functional results of a consecutive series of pa-ients who underwent this novel reconstruction tech-ique with a minimum of 2 years’ follow-up.

METHODS

Institutional review board approval was obtained,nd patients were identified through the prospectiveports medicine databases at 2 academic institutions.he inclusion criteria included a disruption of the PLC

diagnosed by physical examination, magnetic reso-ance imaging, and surgical findings), age of 18 yearsr older, minimum follow-up of 2 years, and primaryLC reconstruction (as opposed to PLC repair). Ex-lusion criteria included patients aged younger than 18ears, pregnant women, patients with bilateral kneenjuries, patients with prior surgery of the PLC (openeduction–internal fixation and/or failed repair), andatients who were unable or unwilling to participate inehabilitation of the knee.

All patients sustained injuries to other ligaments inddition to the PLC. The patients were divided into 2

roups based on injury pattern (2 ligament v multi- t

igament). The timing of surgical intervention wasefined as early for patients who underwent recon-truction within 14 days of the time of their injury andelayed for those who underwent reconstruction atreater than 14 days.10,11

All patients underwent an identical surgical tech-ique by 2 surgeons and followed a standard post-perative multiligament rehabilitation protocol asescribed by Fanelli and Edson.12 They were kepton–weight bearing for 6 weeks postoperatively, withhe leg locked in full extension in a hinged knee braceor the first 3 weeks, and then allowed full range-of-otion (ROM) exercises and quadriceps strengthen-

ng with the brace unlocked. Hamstring exercisesere restricted until 4 months postoperatively, andatients were allowed to return to full activities at 8 to2 months, depending on the extent of their surgicaleconstruction (i.e., number of ligaments recon-tructed).

The functional and clinical outcomes were assessedy clinical examination, Lysholm scores,13 and Inter-ational Knee Documentation Committee (IKDC)ubjective scores.14

Clinical examination consisted of side-to-side kneeomparison and included several parameters. Gait wasssessed for adductor thrust. Passive knee ROM wasecorded. Anterior cruciate ligament (ACL) integrityas assessed by use of the Lachman examination

graded as 0, 1, 2, or 3).15 Posterior cruciate ligamentPCL) integrity was assessed by use of the posteriorrawer test at 90° of knee flexion (graded as 0, 1, 2, or).16 Medial collateral ligament integrity was assessedy use of the valgus stress test at 0° and 30° of flexiongraded as 0, 1, 2, or 3).17 FCL/PLC integrity wasssessed by use of the varus stress test at 0° and 30° ofexion (graded as 0, 1, 2, or 3), the external rotation/osterior drawer test at 90° of flexion (graded as 0, 1,, or 3), and the dial test at 30° of flexion in a proneosition (determined to be abnormal with a side-to-ide difference �15°).12,16

Paired comparisons were performed by use of Wil-oxon signed rank tests. Multivariate regression wassed to analyze the outcome effects of any indepen-ent variables showing a significant difference be-ween groups. Significance was set at .05. Statisticalnalysis was performed with JMP Statistical Discov-ry Software, version 7.0 (SAS Institute, Cary, NC).

urgical Technique

Our surgical technique is shown in Fig 1. The

echnique begins with an incision carried out over the
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234 S. J. SCHECHINGER ET AL.

FIGURE 1. (A) Tunnel placementand graft construct. (B) Graft con-struct, followed by posterolateralcapsular shift.

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235ACHILLES TENDON ALLOGRAFT RECONSTRUCTION

ateral epicondyle extending toward the anterior bor-er of the fibula. Anterior and posterior full-thicknesskin flaps are raised to expose the iliotibial band andhe biceps femoris muscle complex. The peronealerve is identified posterior to the biceps femoris andollowed proximally and distally to ensure that it is notethered through its course and enabling its protectionhroughout the procedure with the aid of a vessel loop.he iliotibial band is then incised in line with the skin

ncision. The anterior and posterior borders of thebula are identified, and subperiosteal dissection iserformed, by use of a Bovey and small Cobb. Afterxposure of the fibular head, access to the anteriorulcus of the popliteus and insertion of the FCL isreated with dissection over the lateral aspect of theemur. A tract is developed from the posterior borderf the fibula, underneath the biceps femoris, and to-ard the popliteus sulcus for later passage of the graft.nder fluoroscopic control, a K-wire is passed

hrough the anterior one fifth of the popliteal sulcusnd then over-reamed with a 9-mm reamer to a depthf 20 mm (Fig 2). A nonirradiated fresh-frozen Achil-es tendon allograft with a 9 � 20–mm bone plug onne end and 7-mm graft along its tendinous portion isrepared (Fig 3A). The bone plug of the allograft ishen placed into the tunnel created at the popliteusulcus and secured with an 8 � 20-mm metal inter-erence screw allowing for bone-bone fixation (FigB). After securing of the graft, the fibular tunnel ishen prepared. Under fluoroscopic guidance, a K-wires passed from the anterolateral fibula at the attach-ent site of the FCL to the posteromedial down-slope

f the fibular styloid, where the PFL attaches to theosterior border of the fibula (Fig 3B). Once in theppropriate position, the K-wire is then over-reamedith a 7-mm reamer. The graft is passed underneath

he biceps femoris through the tract that was previ-usly developed, and a suture passer is passed anterioro posterior through the 7-mm hole in the fibula. Athis point, the graft is passed posterior to anteriorhrough the fibula, re-creating the popliteal fibularigament. The graft is then looped back over to theateral epicondyle at the insertion of the FCL, approx-mately 18.5 mm proximal and posterior to the popli-eus tendon insertion, to re-create the FCL.6 Oncegain, under fluoroscopic control, a Beath pin isassed at the FCL insertion to ensure that its path isot intruding on other reconstructed ligament tunnelsFig 4A and B). With the Beath pin in place, the graft ishecked for isometry in flexion and extension (Fig 4Cnd D).

Once isometry is attained, a 7-mm drill is passed 2

ver the Beath pin to a depth of approximately 40 mmFig 4E). The Beath pin technique is used to pass theraft from the lateral to the proximal and medial sidef the knee. The Beath pin and sutures are pulled outf the medial side of the knee, to apply tension to theraft construct. The graft is tensioned with the leg atpproximately 30° of flexion, 10° to 15° of internalotation, and maximum valgus.7 The graft is securedith an 8 � 30-mm bioabsorbable screw, completing

he FCL reconstruction (Fig 5). The FCL and PFLimbs of the graft are now imbricated with No. 1thibond suture (Ethicon, Somerville, NJ).The posterolateral capsular shift is then performed

n the following manner. The capsule is released offhe distal femur, with subperiosteal dissection with aovey and Cobb. By use of 3 or 4 No. 1 Ethibond

utures, the sutures are passed from the posterolateralapsule, imbricated distally and anteriorly, and se-ured to the graft reconstruction complex, providingdditional strength to the reconstruction (Fig 6).

All wounds are irrigated with normal saline solu-ion, and the iliotibial band fascia is closed with in-errupted No. 1 Ethibond suture, the subcutaneousayers are closed with No. 2-0 Vicryl (Ethicon), andhe skin is closed by use of running No. 3-0 Mono-ryl (Ethicon) with Steri-Strips (3M, St Paul, MN).ostoperative radiographs are obtained (Fig 7).The reconstruction is unloaded by placing the knee

n a valgus-producing hinged knee brace locked in fullxtension. Any off-the-shelf hinged rehabilitationnee brace can be used, by applying a valgus bend tohe brace. This brace is typically worn for the first 6eeks postoperatively, until soft-tissue swelling sub-

ides. Thereafter the patient’s knee is placed in austom valgus-producing unloader brace for approxi-ately 8 to 12 months.When indicated, our ACL reconstruction technique

onsisted of an arthroscopically assisted single-bun-le, transtibial reconstruction, using soft-tissue allo-rafts with cortical fixation on the femur and bioab-orbable screw fixation on the tibia.

When indicated, our PCL reconstruction techniqueonsisted of an arthroscopically assisted anterolateralingle-bundle, transtibial reconstruction, using Achil-es tendon allografts with metal interference screwxation on the femur and bioabsorbable screw fixationn the tibia.

RESULTS

Between January 2002 and March 2006, 20 knees in

0 patients were identified through our prospective
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236 S. J. SCHECHINGER ET AL.

ports medicine databases as having undergone PLCeconstruction with the previously mentioned tech-ique, with a minimum of 2 years’ follow-up. On theasis of our inclusion and exclusion criteria, 2 patients

ere excluded because of contralateral knee injury w

nd 2 patients because of prior surgery to the PLC.hus our study comprised 16 knees in 16 patients: 13en and 3 women. The mean age was 30 years (range,

9 to 61 years). The mean length of clinical follow-up

IGURE 2. (A) Fluoroscopic anteroposterior view of-wire position for femoral tunnel in popliteal sulcus.) Fluoroscopic lateral view of K-wire position formoral tunnel in popliteal sulcus. (C) Fluoroscopicteroposterior view of 9-mm reamer, reamed to apth of 20 mm.

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237ACHILLES TENDON ALLOGRAFT RECONSTRUCTION

nism of injury was considered high energy (i.e.,otor vehicle accident) in 11 patients (69%) and low

nergy (i.e., sports trauma) in the remaining 5 (31%).Various patterns of injury were noted in the study

roup and are outlined in Tables 1 and 2. The 2-lig-ment injury group consisted of 7 patients who hadustained either an ACL (5) or PCL (2) injury inombination with the PLC, and the multiligamentroup consisted of all other injury patterns (9 pa-ients).

The timing of surgical intervention from injury dates detailed in Table 3. No patients underwent surgicaleconstruction before 2 weeks from the time of theirnjury. Therefore all patients included in the studyroup underwent delayed reconstructions (�2 weeks).verall, the mean time to reconstruction was 130 days

range, 17 to 731 days). The mean time from injury toeconstruction in the 2-ligament injury group was 109ays (range, 17 to 266 days), and that in the multi-igament group was 207 days (range, 19 to 731 days).his difference was not statistically significant (P �

10). The wide variability in the timing of surgicalntervention was a result of patients who were eithernable to undergo surgical reconstruction because ofssociated injuries or those who presented with

IGURE 3. (A) Achilles tendon allograftith 9 � 20–mm bone plug and 7-mmraft. (B) Fluoroscopic anteroposterioriew of bone block secured with metalnterference screw at popliteal sulcus and-wire placement for fibular tunnel.

hronic instability. For example, 1 polytrauma patient e

ad a fracture-dislocation of the ipsilateral hip, with aomplex acetabular fracture, and did not regain fulleight-bearing status until over 6 months from the

njury, at which time an unrecognized multiligamentnee injury became apparent. This patient underwenteconstruction at 393 days after injury. Another pa-ient sustained a low-energy multiligament knee injurynd was treated nonoperatively for almost 2 yearsefore referral. This patient underwent reconstructiont 731 days after injury.

The mean IKDC subjective score in the 2-liga-ent injury group was 80 points (range, 50 to 92

oints), and the mean Lysholm score was 90 pointsrange, 75 to 100 points). The mean IKDC subjec-ive and Lysholm scores for the multiligamentroup were 80 points (range, 30 to 99 points) and 89oints (range, 60 to 99 points), respectively. Meannee ROM was 132° (range, 100° to 150°) in the-ligament group and 118° (range, 80° to 145°) inhe multiligament group. At final follow-up, clinicalxamination comparing the injured and contralat-ral knee in the 2-ligament group showed no side-o-side difference in lateral laxity (grade 0) at 0° or0° in 5 patients and grade 1� laxity (1 to 5 mm) at0° in 2 patients, with varus stress testing. Clinical

xamination comparing the injured and contralat-
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238 S. J. SCHECHINGER ET AL.

FIGURE 4. (A) Fluoroscopic anteroposterior view of K-wireposition for femoral tunnel at isometric point, adjacent tolateral epicondyle. (B) Fluoroscopic lateral view of K-wireposition for femoral tunnel at isometric point, adjacent tolateral epicondyle. (C) Intraoperative photograph of isometricpoint at 90° of flexion. (D) Intraoperative photograph ofisometric point in full extension. (E) Fluoroscopic anteropos-terior view of FCL tunnel reamed with a 7-mm reamer to adepth of approximately 40 mm.

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239ACHILLES TENDON ALLOGRAFT RECONSTRUCTION

ral knee in the multiligament group showed noide-to-side difference in lateral laxity (grade 0) at° or 30° in 7 patients (78%) and grade 1� laxity (1o 5 mm) at 30° in 2 patients (22%), with varustress testing. No patient in either group had varusaxity in full extension, varus laxity of grade 2� orore at 30°, or adductor thrust with ambulation,

nd none had posterolateral rotatory instabilitypon dial and external rotation/posterior draweresting.

Wilcoxon paired rank-sum tests showed no statisti-ally significant differences between the 2 groups inerms of ROM (P � .18), IKDC subjective scoresP � .79), or Lysholm scores (P � .96). Multivariateegression showed no significant effect of age (P �

IGURE 5. Intraoperative photograph of FCL and PFL ligamenteconstruction.

IGURE 6. Intraoperative photograph of posterolateral capsularhift.

T

41), gender (P � .84), or interval between injury andurgery (P � .72) on the outcomes of the 2 groups.

Complications included arthrofibrosis and a chronicegional pain syndrome in 1 patient in the multiliga-ent group. No patient in either group has required

evision reconstruction to date.

DISCUSSION

Numerous PLC techniques have been described inhe literature with varying degrees of success.8,12,18,19

tannard et al.18 described a technique for reconstruc-

IGURE 7. Postoperative anteroposterior view of 4-ligamenteconstruction.

TABLE 1. Two-Ligament PLC-Based Injury Patterns

No. of PatientsMean IKDC

Score (Points)Mean LysholmScore (Points)

njury PatternACL/PLC 5 (31%) 86 95PCL/PLC 2 (13%) 63 77

otal 7 (44%) 80 90

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240 S. J. SCHECHINGER ET AL.

ion of the PLC in 22 knees with minimum follow-upf 24 months. They used a modified 2-tailed techniquehat reconstructs the PFL and FCL through transtibialnd transfibular bone tunnels and around a singlecrew on the lateral femoral condyle. Mean ROM was33°. The mean Lysholm knee score was 90 points forhe entire group, with scores of 92 points for theultiligamentous knees and 88 points for the isolatedLC reconstructions. There were 2 failures in theultiligamentous knee injury group (13%), as com-

ared with no failures in the isolated PLC group.Strobel et al.19 evaluated clinical outcomes after

ingle-stage ACL, PCL, and PLC reconstruction in 17atients with chronic knee injuries at a minimumollow-up of 24 months. The PLC was reconstructedith a graft passed through the proximal fibula, withoth graft limbs inserting at an isometric point on theemur. At final IKDC evaluation, the results wereraded as nearly normal in 4 patients (29.4%), abnor-al in 10 (58.8%), and grossly abnormal in 2 (11.8%).

TABLE 2. Multiligament PLC-Based Injury Patterns

No. ofPatients

Mean IKDCScore (Points)

Mean LysholmScore (Points)

njury PatternACL/PCL/PLC 5 (31%) 72 83ACL/PCL/MCL/PLC 3 (19%) 87 96ACL/MCL/PLC 1 (6%) 99 95

otal 9 (56%) 80 89

Abbreviation: MCL, medial collateral ligament.

TABLE 3.

Patient No. Age (yr) Sex Injury Pattern Time to S

1 19 F ACL/PLC 62 32 M ACL/PLC 83 22 M ACL/PLC 104 23 M ACL/PLC 145 33 M ACL/PLC 266 37 M PCL/PLC 37 61 M PCL/PLC 78 36 M ACL/PCL/PLC 19 23 M ACL/PCL/PLC 2

10 24 F ACL/PCL/PLC 211 20 M ACL/PCL/PLC 512 22 M ACL/PCL/PLC 3913 29 M ACL/MCL/PLC 7314 27 F ACL/PCL/MCL/PLC 115 32 M ACL/PCL/MCL/PLC 216 35 M ACL/PCL/MCL/PLC 3

Abbreviation: MCL, medial collateral ligament.

he mean postoperative subjective IKDC score was1.8 � 19.3 points.Our series found ROM data and IKDC and Lysholm

cores consistent with the previously described liter-ture. Several patients in our series were involved inigh-energy activities causing significant soft-tissueamage to their limbs, which ultimately had a nega-ive impact on their clinical and functional outcomes.wo patients in particular had relatively lower ROMs well as IKDC and Lysholm scores compared withhe rest of the study group. The first patient (Table 3,atient 10) sustained a 2-ligament knee injury (PCL/LC), as well as a severe soft-tissue injury to theroximal tibia region, leading to an infected hema-oma, which required several surgical interventions.t latest follow-up, this patient still had chronic pain

nd swelling in the lower leg. The second patientTable 3, patient 10) sustained a multiligament kneenjury with severe capsular disruption. In this patientrthrofibrosis developed, requiring manipulation un-er anesthesia and arthroscopic lysis of adhesions. Shead subsequent development of a regional pain syn-rome that is currently unresolved.The reconstruction technique used in this series is

imilar to that described by Arciero20 in that the PFL andCL are reconstructed in a process that re-creates theemoral and fibular insertions of the 2 ligaments. However,ur technique is unique in that the posterolateralapsule is then imbricated to our ligamentous re-onstruction to further enhance varus and externalotatory stability.

ent Data

(d) ROM (°) IKDC Score (Points) Lysholm Score (Points)

140 91 95150 92 100140 84 88150 74 92130 90 100100 80 82115 46 72145 86 95115 89 9580 30 60

140 90 94130 66 73115 99 95105 85 99135 95 9990 82 91

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241ACHILLES TENDON ALLOGRAFT RECONSTRUCTION

Several biomechanical studies have shown restora-ion of varus and external rotational stability withnatomic PLC reconstruction techniques.7,21 The re-onstructive technique used in this series also hasiomechanical support. Nau et al.21 described a tech-ique similar to ours with regard to the PFL and FCLraft placement in 10 cadaveric specimens and com-ared this with an anatomic reconstructive techniqueescribed by LaPrade et al.7 The reconstructions wereested for varus and external rotatory stability. Theesults of this biomechanical analysis yielded similarutcomes for static ligamentous stability testing be-ween both groups.

Our study has several limitations including a rela-ively small sample size, heterogeneity of the studyroup, variability in the timing of surgical interven-ion, and lack of objective testing of the FCL and PLCeconstruction.

The uncommon nature of isolated PLC injuriesakes it difficult to obtain a completely homogeneous

tudy group. In fact, no patients in our series had ansolated PLC injury. In an effort to minimize hetero-eneity, we did the following. First, we reported onlyn those patients who underwent primary PLC recon-truction and excluded those who had any previousurgery to the PLC. Second, we excluded patients whoad contralateral knee injuries. It is difficult to deter-ine functional outcome scores in those patients be-

ause of the inability to perform side-to-side compar-sons, as well as the patients’ inability to participate inehabilitation. Lastly, we divided our study group into

groups (2-ligament v multiligament injuries). The-ligament group (ACL/PLC, PCL/PLC) representshe more frequently encountered injury patterns asso-iated with PLC injuries, whereas the multiligamentroup is less common. Although these efforts resultedn less heterogeneity, drawing valid conclusions fromhis study group remains difficult.

With regard to the timing of surgical intervention,he literature is unclear in the definition of early versuselayed reconstruction in the setting of combined lig-ment injuries of the knee.11,12,22 Several authors de-ne early as less than 2 weeks,10,11 and others define its less than 3 weeks.22 On the basis of the outcomes inhe current literature,12 we typically perform early sur-ical management of all damaged ligamentous structureshenever possible. In this series, however, several pa-

ients presented with chronic instability whereas othersresented with polytrauma and surgical intervention waselayed because of associated injuries. Multivariate re-

ression analysis showed that the timing of surgery did

ot affect the clinical and functional outcomes be-ween the 2 groups.

In our study stability was assessed through physicalxamination alone; thus there was a lack of objectiveesting of the FCL and PLC reconstruction. Recently,oyes and Barber-Westin22 reported on the use ofostoperative comparison stress radiography to assessLC stability. Although we recognize the benefits oftress radiography, we have found this technique difficulto perform in a reliable and reproducible fashion.

The main advantage of our reconstructive techniques that it does not require the creation of a tibial tunnelith additional graft passage and is therefore less

omplex than other previously described anatomicechniques. Another unique feature of this technique ishe advancement of the posterolateral capsule, whichs recognized as a static stabilizer.

The main disadvantage of this surgical technique ishe necessity for an intact proximal tibiofibular jointecause the reconstruction is tensioned through thebula, not the tibia. Biomechanically, one would pos-

ulate that securing the grafts to the tibia should bedvantageous. A biomechanical cadaveric study wouldeed to be done comparing the “anatomic” techniqueith our technique (addressing the posterior capsule)

o determine whether the posterolateral capsular shiftffers a biomechanical advantage. Furthermore, clin-cal comparative studies would need to be performedo assess any differences among the techniques withegard to functional outcomes.

Although no patients have required revision recon-truction to date, 4 patients (25%) had subtle residualaxity (1�) to varus stress at 30°. Whether this resid-al laxity will result in functional instability in theuture remains to be seen.

CONCLUSIONS

We describe a novel technique that takes into ac-ount the main static PLC stabilizers (PFL, FCL, andosterolateral capsule) that has not been previouslyeported. Our series showed no significant differencesn clinical and functional outcomes between 2-liga-ent and multiligament PLC-based reconstructions.owever, given the heterogeneity and small sample

ize of our study group, it is difficult to draw qualita-ive conclusions.

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